Monday, June 1, 2020

“The county has been cleared to open up restaurants and stores this week.”

We are three months into adjusting to life with COVID-19. Our day-to-day routine for the foreseeable future has drastically changed. As much as I held out hope, like everyone else, for a return to normalcy, I have accepted that the virus will be a part of life, as ubiquitous as the flu but more deadly. We will continue to take extra precautions to protect our families and work in clinics and hospitals to keep COVID-19 at bay.

I don’t deny sometimes feeling apathetic, but just when I do, I hear cases like this: “A friend came to visit me; we hung at my house, and a week later I received a phone call that I really didn’t want to get. My friend tested positive. I am here to get tested because I am concerned I was exposed. I have no symptoms. What should I do? Should I tell others I might have it? Should I tell them to get tested too? How long should I wait?”

Variations of this conversation occur again and again as counties and states open up. Patients come to us after isolating for months at home, only to be exposed by a single visit. I understand the angst, loneliness, and frustration that they overcame to reach this point. Their adherence to “stay-at-home orders” was evident in the slowed rate of rise of COVID-19 across the country.

By staying at home and taking precautions, people gave businesses and health systems time to better prepare and restructure operations to limit in-person contact. Now, as more places open up and people come into contact, questions and concerns regarding cases of COVID-19 and non-COVID-19 related medical issues will rise. I see people trying their best to balance their mental health needs with the reality of the risks of COVID-19. Most keep their masks on. When people meet, they stay outdoors and try to keep away from enclosed spaces.

How can we manage the built-up demand for health care while the threat of COVID-19 still stalks clinics and hospitals? Telemedicine will likely be at the forefront. At our residency clinic, video visits outnumber in-person visits now. Other clinics, like the one where Dr. Erika Roshanravan works, have added telephone visits. “People love it! It makes sense. It is more convenient for people. There are still visits that we have to do in-person” but there are now more options and avenues for patients to reach us, she says.

As the weather warms, we will all be called outdoors to barbeque pits, lush grass fields, glistening waters, and a longing to feel “normal” again. I want people to enjoy themselves, but I also want everyone to stay safe. When you need care, whether for a routine medical problem or COVID-19 related concern, I will still be here: ready with my face shield, mask, gown and gloves to help and serve you. I can’t promise that we have all the answers yet, but we will try our best. As we move forward into in a brave new COVID world, I hope that my friends, family, and neighbors will continue to act in ways that do not increase the risks to the most vulnerable among us. As Dr. Roshanravan says, “this is not a sprint, it’s a marathon.”

The study authors reviewed data from over 96,000 patients across 671 hospitals worldwide of patients who were admitted with a positive SARS-CoV-2 test and divided them into cohorts of those who received hydroxychloroquine or chloroquine, with or without a macrolide (most commonly azithromycin), and those who did not receive any of those medications (the control group). Included patients received one or more of these medications within 48 hours of admission, were not on mechanical ventilation when the regimen was started, and did not receive antiviral treatment with remdesivir:

These specific exclusion criteria were established to avoid enrolment [sic] of patients in whom the treatment might have started at non-uniform times during the course of their COVID-19 illness and to exclude individuals for whom the drug regimen might have been used during a critical phase of illness, which could skew the interpretation of the results. Thus, we defined four distinct treatment groups, in which all patients started therapy within 48 h of an established COVID-19 diagnosis: chloroquine alone, chloroquine with a macrolide, hydroxychloroquine alone, or hydroxychloroquine with a macrolide. All other included patients served as the control population.

Monday, May 18, 2020

One of the few comforting findings in the COVID-19 pandemic has been that most children older than one year of age have a less severe clinical course than adults. A large case series from China suggested that about half of infected children have mild symptoms (acute upper respiratory tract infection or gastrointestinal symptoms, including diarrhea) while only 1 in 20 develop hypoxia, respiratory failure, or other organ failure. In a U.S. case series, two-thirds of infants younger than 12 months were hospitalized; the corresponding figure in older children was 5 to 15 percent. As a pediatric infectious diseases specialist at New York University recently told a New York Times reporter, "The idea that children either don't get COVID-19 or have really mild disease is an oversimplification."

On April 7, Hospital Pediatrics published a case report of a 6 month-old infant who was hospitalized for classic Kawasaki disease and had a positive result on a reverse transcription polymerase chain reaction (RT-PCR) test for COVID-19. At that time, it was not clear if the COVID-19 diagnosis was coincidental or associated with this rare vascular inflammatory condition. On May 7, the Lancet published a report of a cluster of 8 cases of children with hyperinflammatory shock (atypical Kawasaki disease, Kawasaki disease shock syndrome, or toxic shock syndrome) who presented to a children's hospital in London during a 10-day period in the middle of April. Within one week, more than 20 children with similar clinical features were admitted to the pediatric intensive care unit (PICU), half of whom tested positive for SARS-CoV-2.

In Bergamo, Italy, the incidence of Kawasaki-like disease increased 30-fold between February and April at the height of the epidemic. Compared to a historical group of children with Kawasaki disease prior to the pandemic, these children were older and had a higher rate of cardiac complications. Investigators in France and Switzerland described a series of 35 children (31 of whom tested positive for SARS-CoV-2) who were treated in PICUs for acute heart failure due to a severe inflammatory state.

Last week, the U.S. Centers for Disease Control and Prevention (CDC) issued an official health advisory to provide information to clinicians about multisystem inflammatory system in children (MIS-C) associated with COVID-19. The case definition for MIS-C is as follows:

- Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or COVID-19 exposure within the 4 weeks prior to the onset of symptoms.

Fortunately, standard treatment for Kawasaki disease (described in a 2015 article in AFP), including intravenous immunoglobulin, corticosteroids, and aspirin, thus far appears to be effective in treating MIS-C associated with COVID-19.

To address the need for a culturally tailored standard for diabetes care during the month of Ramadan, a multidisciplinary team of clinicians gathered to design an empowerment-based collaborative clinical tool called the Fasting Algorithm for Singaporeans with Type 2 Diabetes (FAST). It is a stepwise clinical decision-making tool with risk-assessment screening, Ramadan-specific patient education with self-monitoring of blood glucose (SMBG), structured glucose-lowering medication modification guidance for health care clinicians, and novel self-dose adjustment guidance based on SMBG readings during Ramadan.

The researchers randomized 97 patients with type 2 diabetes who planned to observe fasting during the month of Ramadan into an intervention group (using the FAST tool) or a placebo group (usual care). Participants were excluded if their baseline hemoglobin A1c was greater than 9.5%. Study groups were further stratified into patients using and not using insulin. Intervention group participants had improved fasting blood sugars (-3.6 mg/dL vs +20.9 mg/dL in the control group for a difference of 24.5 mg/dL [95% confidence interval 11.3-37.7]) with no statistically significant difference in postprandial blood sugars compared to participants in the control group. There were no major hypoglycemic events in either group. The intervention group had 1 verified minor hypoglycemic event and the control group had 5, though this difference was not statistically significant. Although the study authors lauded the improvements in the intervention group's blood sugars during the trial, more patient-oriented outcomes such as hypoglycemia were not significantly different (though it's possible that a better powered trial might have demonstrated a more robust difference). At the very least, though, the FAST tool appears to provide a culturally respectful approach to frame discussions with patients with type 2 diabetes planning to fast during the month of Ramadan.

Monday, May 4, 2020

For this post, I interviewed medical students in their second, third, and fourth years to share some of the ways that COVID-19 has impacted their education, training, and understanding of medicine going forward.

“When [we] hear ‘we need more doctors and providers!’ we want to [help] but we can’t right now. It is a weird thing,” says second-year student Alicia Hobbs (AH).

Medical students usually follow a strict timeline of classes, rotations, and examinations. Going through medical school is like “drinking from a fire hose.” It requires a constant balance of time, energy, learning, and growth. This path was altered by COVID-19.

AH had only been two weeks into her dedicated study time for the United States Medical Licensing Examination (USMLE) Step 1. Amidst her studying, she followed the news about the pandemic and grew more concerned as the situation evolved. Eventually the test that was scheduled for April got moved back to May. She is still not sure if it will happen. Her “clinical rotations have changed as well. [They] were supposed to start third year in the first week of May; that has been pushed back to mid-July now.”

Michelle Do (MD) explains that she had her fellow third year medical students are “kind of in between. We know some clinical duties; [each person’s] skill varies based on the rotations they did. ... Most medical students want to help - they care about the community.” Many are volunteering at drive-through screening sites, picking up groceries for people who can’t get them, providing child care, participating in “phone-a-senior” groups, and staying involved as much as they can. Still, the impact of COVID-19 is apparent. Their fourth year schedules - carefully planned with specialty-specific away rotations or sub-internships in other locations - are now up in the air. Their USMLE Step 2 examinations have been postponed, too.

Perhaps the most bittersweet changes have affected fourth year medical students. When most “stay-at-home” orders started, students all over the U.S. were waiting for the much anticipated Match letters that announced where they would be going for their residency. Not only was Match Day changed into a virtual experience, graduation ceremonies will be different as well. Many students like Libby Wetterer now have the interesting task of planning to move to another city or state from a distance. She has “begun to do purely virtual apartment searching” and has been also having “Zoom calls and group chats with her soon to be co-residents.”

MD, like many students, feels “conflicted - [she] wants a good educational experience, but [she] is also worried about being an asymptomatic carrier.” AH is thinking about the implications for COVID testing “knowing who’s immune and who’s not. [We are thinking about] how to look at a systems-approach for when something like this happens again. How to have better screening, stockpiles, PPE, etc.” The situation may put a different perspective on what scope of care they may select in the future. Students have begun to talk about the breadth of specialties - whether a particular specialty is so narrow that they can no longer do intubations, or if they would even want to do intubations in hazardous situations like this in the future.

Restrictions on participating in direct patient care recommended by the American Association of Medical Colleges were intended to safeguard their health, but medical students have been left feeling torn. They see their calling, but they also recognize the barriers. Rather than be disheartened, they are instead instinctively finding creative ways to support practicing health professionals and their communities.

Monday, April 27, 2020

Anecdotal reports are emerging of patients with COVID-19 presenting with purplish patches on their toes. Sometimes, these findings are the only sign of otherwise asymptomatic COVID-19, and sometimes they are the initial presenting sign in advance of fever and upper respiratory symptoms. These skin findings (more details here and here) look remarkably similar to pernio (chilblains):

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